PowerPoint Presentation · (NovoLog), determir (levemir), 70/30 mix insulin (NovoLog and Novolin 70/30), ... groups for the Insulet Corporation •They make an insulin delivery system

1/16/2017

1

Insulin Therapy For DiabetesMichigan Association of Osteopathic Family Physicians

Mid-Winter Family Medicine Update

Shanty Creek Resort, MI

January 19-22nd 2017

Michael R. Brennan D.O., M.S., F.A.C.E

Director Beaumont Endocrine Center

Chief of Endocrine Beaumont Grosse Pointe

• I’m married to a drug representative and she works for Novo Nordisk

• Makers of liraglutide (Victoza/Saxsenda), aspart (NovoLog), determir (levemir), 70/30 mix insulin (NovoLog and Novolin 70/30), degludec (Tresiba), repaglinide (Prandin), glucagon (GlucaGen HypoKit), estradiol vaginal tablets (Vagifem), estradiol/norethindrone (Activella), somatropin (Norditropin), coagulation factor VIIIa (NovoSeven)

• I’m a consultant on insulin pumps and lead groups for the Insulet Corporation• They make an insulin delivery system (pod/pump)

called the Omni Pod

1/16/2017 2

Disclosure

1/16/2017 3

1/16/2017

2

1/16/2017 4

1/16/2017 5

Resources

1/16/2017 6

1/16/2017

3

Resources – 2017 ADA

1/16/2017 7

Resources -https://www.aace.com/publications/algorithm

1/16/2017 8

9

Objectives

• To understand the general “types” of insulin

• Be able to start and dose a patient on a reasonable amount of insulin therapy in a physiologic replacement pattern

• Be aware of all continuous insulin infusion devices (insulin pumps, pods and patches)

• Understand the device settings of a continuous insulin infusion device (pump)

1/16/2017

4

10

Background/Physiology

• The physiologic range of insulin

produced by the body in a normal

individual 0.3 to 0.5 units/kg per day

• Half a person’s daily pancreatic insulin secretion is basal (chronic relatively constant secretion) and half is bolus (secreted in bursts with hyperglycemia)

• Most people you see have insulin resistance and will be slightly beyond the physiologic range

11

All Diabetes Classes of Medication

• Bigunides

• Alpha-Glucosidase Inhibitors

• Amylin Mimetic

• Bile Acid Sequestrants

• Dipeptidyl Peptidase-4 inhibitor

• Dopamine-2 Agonist

Glucagon-Like Peptide-1

Inhaled insulin

Meglitinides

Thiazolidinedione

Sodium-glucose transporter 2

Sulfonylurea

Subcutaneous/IV Insulin

12

Insulin

Four Generalized Classes:

• Basal Insulin

• Rapid Acting Insulin

• Regular Insulin

• Mix Insulin

1/16/2017

5

13

InsulinBasal insulin: Insulin administered to cover

endogenous glucose production (glucose

made by the liver/body). Doses can be

administered subcutaneously one, two, or

three shots per day

•Glargine (Lantus/Toujeo/Basaglar)

•Detemir (Levemir)

•Degludec U-100 and U-200 (Tresiba)

•Neutral Protamine Hagedorn (NPH, Humulin N or Novolin N)

14

InsulinRapid acting insulin – Covers the glucose

created by stress, consumption of glucose

or infusion of glucose. It is used in

subcutaneous bolus method to correct or

prevent hyperglycemia

• Lispro and Lispro U-200 (Humalog)

• Glulisine (Apidra)

• Aspart (Novolog)

15

Insulin

Regular insulin – Conceptually can be considered

the first insulin (just the human insulin molecule).

No substitutions in molecule configurations, amino

acids. Now relatively slow compared to rapid

insulin, and not long acting compared to basal for

subcutaneous use. Great for IV use as it is

inexpensive and extremely effective. Regular

insulin has a short IV half-life, which can be a

problem in a patient that requires insulin.

• Regular insulin (Humulin R, Novolin R)

1/16/2017

6

16

InsulinMix insulin – An attempt to cover both meal and

endogenous glucose in one shot. This is not an

ideal insulin with fluctuating PO intake (e.g. the

hospital). Dosed generally before breakfast and

dinner or before all meals:

• 30% Aspart, 70% Prot-aspart (NovoLog 70/30)

• 30% Novolin-R, 70% NPH (Novolin 70/30)

• 25% Lispro, 75% Prot-Lispro (Humalog 75/25)

• 30% Humulin-R, 70% NPH (Humulin 70/30)

• 50% Lispro, 50% Prot-Lispro (Humalog 50/50)

17

InsulinConcentrated Insulin – Insulin resistance can be

so severe that the volume of the insulin injection

can be overwhelming. Therefore, the units of

insulin can be manufactured in a smaller volume.

• U-500 Regular

• U-300 Glargine (Toujeo)

• U-200 Lispro (U-200 Humalog)

• U-200 Degludec (U-200 Tresiba)

18

Basic Slide Header• Theoretical insulin secretion (always normal glucose levels)

“Normal” secretion of insulin

Insulin duration over 24 hours

Insulin

secretion

1/16/2017

7

1/16/2017 19

Starting Basal Insulin• Basal insulin covers endogenous glucose

production (glucose made by body)

• Basal insulin – Dose can be one or two shots per day:

• Start patient on 0.25 units per kg/d

– Glargine (Lantus/Toujeo/Basaglar) – Indicated for once a day dosing

– Detemir (Levemir) – Indicated for once or twice a day dosing

– Degludec (Tresiba) – Indicated for once a day

1/16/2017 20

Basic Slide Header• Theoretical insulin secretion and duration with one basal shot

Basal Insulin


Insulin

secretion

1/16/2017 21

Basic Slide HeaderBasal Insulin


• Theoretical insulin secretion and duration with two basal shot regimen

Insulin

secretion

1/16/2017

8

1/16/2017 22

Basic Slide Header• Theoretical insulin secretion and duration with three rapid

acting shots

Rapid acting insulin


Insulin

secretion

1/16/2017 23

Basic Slide Header• An attempt to cover both meal and endogenous glucose in

one shot

• Mix insulin – Dose generally before breakfast and dinner or before all meals:

• Start patient on 0.5 units per kilogram per day and divide the dose by 2-3 to determine the doses for the day

– 30% Aspart, 70% Prot-Aspart (NovoLog Mix 70/30)

– 30% Novolin-R, 70% NPH (Novolin 70/30)

– 25% Lispro, 75% Prot-Lispro (Humalog 75/25)

– 30% Humalin-R, 70% NPH (Humulin 70/30)

– 50% Lispro, 50% Prot-Lispro (Humalog 50/50)

Mixed Insulin

1/16/2017 24

Basic Slide HeaderMixed Insulin


• Theoretical insulin secretion and duration with two mix

injections

Insulin

secretion

1/16/2017

9

1/16/2017 25

Basic Slide Header• Theoretical insulin secretion and duration with one basal shot

and three bolus shots

Basal Plus Bolus


Insulin

secretion

1/16/2017 26

Basic Slide Header• Theoretical insulin secretion and duration with two basal shot

and three bolus shots

Basal Plus Two Bolus


Insulin

secretion

1/16/2017 27

Basic Slide Header• Theoretical insulin secretion (always normal glucose levels)

“Normal” secretion of insulin


Insulin

secretion

1/16/2017

10

Basal-Bolus Versus Mix Insulin

1/16/2017 28

• To Simplify:

– Hypoglycemia is less, and meal flexibility is greater in a four to five shot a day regimen using rapid acting and long acting insulin

– On the other hand, frequency of injection is less using a two to three shots per day mixed insulin regimen. In this scenario, hypoglycemia is greater and flexibility is less

Insulin

1/16/2017 29

• The physiologic range of insulin produced by the body in a normal individual 0.3 to 0.5 units/kg per day

1/16/2017 30

Basic Slide Header

• Example #1: a 72kg T1DM admitted and treated for DKA, is now ready to transition to sub Q insulin using basal bolus (4 shots):

– 0.5units/kg/day * 72 kg = 36 units per day

– Choose 18 units of basal

– The (18/3) 6 units of rapid acting with meals

– Patient is 72 kg and the total daily dose of insulin is 36 units

Case #1

1/16/2017

11

1/16/2017 31

Basic Slide Header• Example #2: A 100kg T2DM admitted and

treated for DKA, is now ready to go home (hates shots, but needs them) on sub Q insulin using mix insulin (2 shots):

• 0.5units/kg/day * 100 kg = 50 units per day

• 25 units of mix insulin for breakfast

• 25 units of mix insulin for dinner

• Total daily dose is 50 units of insulin and the patient weighs 100kg

Case #2

Transition Out of the Hospital

1/16/2017 32

• Talk to care management and write scripts before discharge (maybe 2 days before)

– Try to fill the insulin to determine what is available via their insurance (basal, rapid, and mix insulin)

• Insulin within the same class (basal, rapid acting, and mix) can be used similarly

• KEY: Instruct the nurse to give the insulin used at the bedside in the hospital to the patient at discharge

1/16/2017 33

Basic Slide Header

• How do you transition the basal only patient to basal bolus?

– Remember – goal of basal is to titrate the fasting am glucose to 80-130mg/dlNOT to hemoglobin A1C of 7%

– Once goal a.m. glucose (70-120mg/dl) is attained, then you can consider taking that basal dose, dividing it by 3, and administering that number of units 3 times a day with meals

Outpatient Transition

1/16/2017

12

1/16/2017 34

Basic Slide Header

• Example #3: a 120kg T2DM takes 30 units of basal insulin every evening. The a.m. fasting glucoses are 70-150 mg/dl but the HbA1c is 8.9%.

– Starting dose of meal time insulin could be?

Case #3

1/16/2017 35

Basic Slide Header

• Example #3 a 120kg T2DM takes 30 units of basal insulin every evening. a.m. glucoses are 70-150 mg/dl but the HbA1c is 8.9%

– Starting dose of meal time could be:

• 30 units/3 = 10 units rapid acting insulin before meals three times a day

• That’s a total daily dose of 60 units, which in this individual equals 0.5 units/kg/day

Transition Case #3

36

Insulin Delivery

Insulin delivery can generally be done via three

methods of subcutaneous delivery:

• Vial and syringe

• Pens

• Pump/Pods/Patch

1/16/2017

13

37

Vial and Syringe

38

Pens and Pen Needles

39

Pens and Pen Needles

1/16/2017

14

Continuous Insulin Delivery Systems

1/16/2017 40

• Pumps – Company/Pump


1/16/2017 41

• Pumps


1/16/2017 42

• Pods – Company/Pod

1/16/2017

15


1/16/2017 43

• Patch – Company/Patch


1/16/2017 44

• Pods and a patch

Insulin Delivery with Syringe/Pen

1/16/2017 45

• Vial and syringe or insulin pens:

– Mealtime dose/Carbohydrate Ratio

– Basal dose

– Sliding Scale/Correction Factor and Target

1/16/2017

16


1/16/2017 46

• Mealtime Dose:

– Usually aspart (NovoLog), lispro (Humalog), or glulisine (Apidra)

– Example: “I take 10 units before breakfast, lunch and dinner, and like 5 units with snacks.”


1/16/2017 47

Basal Dose - Covers endogenous glucose production (glucose made by body). It will be either glargine (Lantus/Toujeo/Basaglar), detemir (Levemir), or degludec (Tresiba)

• Example:

“I give myself 24 units of Lantus every night”


1/16/2017 48

• Sliding Scale:

– Usually aspart (NovoLog), lispro (Humalog), or glulisine (Apidra)

– Patient uses this scale to “correct” high glucoses (generally Q 4 or AC TID and QHS)

– Example: Glucose (mg/dL) Insulin (units)

150-199 2

200-249 4

250-299 6

300-349 8

>350 10

1/16/2017

17

Insulin Delivery with a Pump/Pod

1/16/2017 49

• Background:

– Based on informal observations by Paul Davidson in 1982, he attempted to calculate a “correction factor” (sliding scale) and a “carbohydrate to insulin ratio” (meal time insulin) for patients with type 1 diabetes (but it applies to anyone with insulin requiring diabetes)


1/16/2017 50

• Insulin for Pump/Pod:– Any insulin can be placed in a pump/pod

– 99% of the time it is a rapid acting analog insulin:• Aspart (NovoLog)

• Lispro (Humalog)

• Glulisine (Apidra)

– Other pump insulin includes:• Regular (Humulin R and Novolin R)

– Used for years prior to rapid acting insulin analogs

• U-500 Regular

• U-200 Lispro


1/16/2017 51

• Pump/Pod:

– Insulin to carbohydrate ratio (Mealtime dose)

– Basal Rate (Basal dose)

– Target glucose and correction factor (Sliding scale)

1/16/2017

18


1/16/2017 52

• Background:

– The carbohydrate to insulin ratio is the insulin required to maintain a static blood sugar per the amount of carbohydrates (in grams) consumed

– Basal Rate is a continuous amount of insulin being infused subcutaneously to keep the patient euglycemic

– The correction factor is the estimated change in blood glucose from one unit of insulin


1/16/2017 53

• Carbohydrate Ratio:

– The carbohydrate ratio is the insulin required to maintain a static blood sugar per the amount of carbohydrates (in grams) consumed

– Example: 1 unit of insulin for every 10 grams of carbohydrate

• If patient is about to eat 80 grams of carbohydrates, then they get 8 units of insulin at meal time

– Carbs in grams are entered in the pump


1/16/2017 54

• Carbohydrate Ratio:

– Advantage:

• Patient can change the amount and the types of food per meals as long as carbohydrates are counted

• Patient can eat at whatever time they like, or however frequently they like

– Both within reason

– Disadvantage – If the Pump/pod fails or gets removed, then there would be no more insulin on board (set up for DKA)

1/16/2017

19


1/16/2017 55

• Basal Rate:

– Instead of Degludec (Tresiba), glargine (Lantus/Toujeo/Basaglar) or detemir (Levemir), a continuous subcutaneous infusion is given with rapid acting insulin (either aspart(NovoLog), lispro(Humalog), or glulisine(Apidra)


1/16/2017 56

• Basal Rate:

– Advantage:

• Rates can be given at various amounts (1/100th of a unit per hour)

• Varying times – the basal rate can be adjusted in half hour increments based on various levels of need



1/16/2017 57

• Basal Rate:

– Example: Basal Rate

• Midnight – 5a.m. = 1.2 units/hr (5 hours, 6 units)

• 5a.m. – 2p.m. = 1 units/hr (9 hours, 9 units)

• 2p.m. – 7p.m. = 1.75 units/hr (5 hours, 10.5 units)

• 7p.m. – Midnight = 0.9 unit/hr (5 hours, 4.5 units)

– Total basal in this case is 30 units of insulin over 24 hours (6 + 9 + 10.5 + 4.5 = 30)

1/16/2017

20


1/16/2017 58

• Basal Rate:

– EXTEREMLY helpful

– BASAL RATE for 24 hours is a great approximation of the basal dose!

• In the previous slide, the patient’s basal rate - Indicates the patient’s basal insulin dose is approximately 30 units of detemir (Levemir), glargine (Lantus/Toujeo/Basaglar) or degludec (Tresiba)


1/16/2017 59

• Target glucose and correction factor:

– Target is chosen by the practitioner

• It is ideally where we would like the individual’s glucose to always be

• People generally choose between 80-150 mg/dL

• I generally choose 90 or 100 mg/dL

– Correction Factor: the estimated amount of blood glucose (mg/dL) that will change with one unit of insulin


1/16/2017 60

• Correction Factor:– The correction factor in mg/dL can be estimated

using 1500 divided by the total daily dose of insulin:

• Example:– Our 100kg gentleman takes 30 units of long acting and 10

units 3 times a day before meals

– Therefore he generally takes 60 units total daily dose (or 0.6units/kg/day)

– 1500 divided by 60 = 25

– Correction factor is 1 unit for every 25mg/dl greater than the target

1/16/2017

21

Pump/Pod vs Sub Q

1/16/2017 61

• Correction Factor (CF):– If the CF is 1 unit for

25mg/dL, and – If the target is 150 mg/dL– Then every 25 mg/dL

greater than the target, the patient gets one unit from the pump

• Example: The patient’s glucose is 225mg/dL, then when the patient tells this info to the pump, the pump suggests 3 units of insulin be administered

• Sliding Scale:

Glucose

(mg/dL)

Insulin (units)

151-200 2

201-250 4

251-300 6

301-350 8

>350 10

IN THIS CASE: SAME EXACT THING!!!

(Just sliding scale has less precision with delivery)


1/16/2017 62

• Correction Factor

– Advantage

• Correction intervals can be in 1mg/dL units (doesn’t have to be every 50 mg/dL)

• The correction insulin dose can be less than 1 unit increments

• The pump can use the known ½ life of the insulin in the pump to prevent insulin stacking



1/16/2017 63

• Correction Factor:

– Extremely useful

– Use this to determine how much insulin it takes to lower a patient’s glucose

• This is helpful if you want to try to lower a person’s glucose by 50mg/dl

1/16/2017

22


1/16/2017 64


– Example #1:

• Patient reports “My correction factor is 1 unit for 25 mg/dL above my target”

• Then you have a clue that in order to lower the blood glucose by 50 mg/dL, it would take approximately 2 units of insulin subcutaneously


1/16/2017 65


– Example #2:


• Then you have a clue that in order to lower the blood glucose by 50 mg/dL, it would take approximately 1.25 units of insulin subcutaneously


1/16/2017 66


– Example #3:


• Then you have a clue that in order to lower the blood glucose by 50 mg/dL, it would take approximately 5 units of insulin subcutaneously

1/16/2017

23


1/16/2017 67

• For an insulin pump patient try to know the following:

– The sum of the basal rate, because then you know the basal dose if needed

– The correction factor, to help estimate how much rapid acting insulin is required to correct the glucose

– Extremely useful if the pump delivery is stopped


1/16/2017 68

• What should a doctor do when the pump fails or is removed?

– Give a basal dose of insulin!!!

• With basal insulin, give at least 0.25 units/kg or the summation of the basal rates

– In Hospital setting: Make sure the attending, team or consultant is aware, takes responsibility, and has an immediate plan of insulin management now that the pump failed

1/16/2017 69

1/16/2017

24

1/16/2017 70

1/16/2017 71

1/16/2017 72

1/16/2017

25

1/16/2017 73

1/16/2017 74

1/16/2017 75

1/16/2017

26

1/16/2017 76

Conclusion

1/16/2017 77

• Insulin is a great medication and frequently required to manage diabetes

• Classify different insulin as either basal, rapid, mix, or regular

• The use of pumps/patches/pods and subcutaneous insulin pens is now common

• Be familiar with knowing:– Basal dose or rate

– Meal time/carb ratio doses

– Sliding scales/correction factors and targets

• The physiologic range of insulin produced by the body in a normal individual 0.3 to 0.5 Units/kg per day

• When in doubt – poke the finger and check the blood glucose, then give insulin when the glucose is too high and glucose if the glucose is too low

Thanks

1/16/2017 78

1/16/2017

27

Questions?

1/16/2017 79

Thank you!

• Questions?

• To Contact Dr. Michael R. Brennan

• Contact the Beaumont Endocrine Center• 25631 Little Mack, Suite 204

• St. Clair Shores, MI 48084

• Phone: 586-443-2380

• Fax: 586-443-2381

• Call Beaumont Health system and ask to have him paged• 248-898-5000

1/16/2017 80

Documents

PowerPoint Presentation · (NovoLog), determir (levemir), 70/30 mix insulin (NovoLog and Novolin 70/30), ... groups for the Insulet Corporation •They make an insulin delivery system